General

Pronunciation:
a-pre-mil-ast

Trade Name(s)

• Otezla

Ther. Class.

antirheumatics

antipsoriatics

Pharm. Class.

phosphodiesterase type 4 inhibitors

Indications

• Active psoriatic arthritis.
• Plaque psoriasis in adults who are candidates for phototherapy or systemic therapy.
• Moderate to severe plaque psoriasis in children who are candidates for phototherapy or systemic therapy.
• Oral ulcers associated with Behçet's disease.

Action

Acts as an inhibitor of phosphodiesterase type 4 (PDE4). Inhibition of PDE4 results in ↑ intracellular levels of cyclic adenosine monophosphate.

Therapeutic Effect(s):

• Reduction in severity of psoriatic arthritis with improved joint function.
• Reduction in severity of plaques.
• Reduction in number of and pain associated with oral ulcers.

Pharmacokinetics

Absorption: 73% absorbed following oral administration.

Distribution: Unknown.

Metabolism and Excretion: Extensively metabolized (mostly by CYP3A4); metabolites are not pharmacologically active. Excreted in urine (58%) and feces (39%) as inactive metabolites; 3% excreted unchanged in urine, 7% in feces.

Half-life: 6–9 hr.

TIME/ACTION PROFILE (plasma concentrations†)

Contraindication/Precautions

Contraindicated in:

• Hypersensitivity;
• Concurrent use of CYP450 enzyme inducers.

Use Cautiously in:

• History of depression or suicidal ideation;
• Severe renal impairment (dose ↓ required for CCr <30 mL/min);
• Taking diuretics or antihypertensive medications (may be at higher risk of complications from severe nausea, vomiting, and diarrhea);
• OB:  Use during pregnancy only if potential maternal benefits justify potential fetal risks;
• Lactation: Use while breastfeeding only if potential maternal benefits justify potential risks to infant;
• Pedi:  Safety and effectiveness not established in children <18 yr (psoriatic arthritis or Behçet's disease) or <6 yr (plaque psoriasis)
• Geri:  Older adults may be at ↑ risk of complications from severe nausea, vomiting, and diarrhea.

Adverse Reactions/Side Effects

GI: diarrhea, nausea, upper abdominal pain, vomiting

Metabolic: weight loss

Neuro: depression, headache

Misc: HYPERSENSITIVITY REACTIONS (including anaphylaxis and angioedema)

* CAPITALS indicate life-threatening.
Underline indicate most frequent.

Interactions

Drug-Drug

Concurrent use of CYP450 inducers, including  carbamazepine,  phenobarbital,  phenytoin  and  rifampin, may ↓ blood levels and effectiveness; concurrent use should be avoided.

Route/Dosage

Adult Patients with Psoriatic Arthritis, Plaque Psoriasis, or Behçet's Disease

PO (Adults): Day 1:  10 mg in the morning;  Day 2:  10 mg in the morning and 10 mg in the evening;  Day 3:  10 mg in the morning and 20 mg in the evening;  Day 4:  20 mg in the morning and 20 mg in the evening;  Day 5:  20 mg in the morning and 30 mg in the evening;  Day 6 and thereafter:  30 mg in the morning and 30 mg in the evening.

Renal Impairment 
PO (Adults): CCr <30 mL/min:  Days 1–3: 10 mg in the morning; Days 4–5: 20 mg in the morning; Day 6 and afterward: 30 mg in the morning.

Children with Moderate to Severe Plaque Psoriasis

PO (Children ≥6 yr and ≥50 kg): Day 1:  10 mg in the morning;  Day 2:  10 mg in the morning and 10 mg in the evening;  Day 3:  10 mg in the morning and 20 mg in the evening;  Day 4:  20 mg in the morning and 20 mg in the evening;  Day 5:  20 mg in the morning and 30 mg in the evening;  Day 6 and thereafter:  30 mg in the morning and 30 mg in the evening.

PO (Children ≥6 yr and 20–<50 kg): Day 1:  10 mg in the morning;  Day 2:  10 mg in the morning and 10 mg in the evening;  Day 3:  10 mg in the morning and 20 mg in the evening;  Day 4:  20 mg in the morning and 20 mg in the evening;  Day 5:  20 mg in the morning and 20 mg in the evening;  Day 6 and thereafter:  20 mg in the morning and 20 mg in the evening.

Renal Impairment 
PO (Children ≥6 yr and ≥50 kg): CCr <30 mL/min:  Days 1–3: 10 mg in the morning; Days 4–5: 20 mg in the morning; Day 6 and afterward: 30 mg in the morning.

Renal Impairment 
PO (Children ≥6 yr and 20–<50 kg): CCr <30 mL/min:  Days 1–3: 10 mg in the morning; Day 4 and afterward: 20 mg in the morning.

Availability (generic available)

Tablets: 10 mg, 20 mg, 30 mg

Assessment

• Assess pain and range of motion before and periodically during therapy.
• Monitor mental status for signs and symptoms of depression (orientation, mood behavior) frequently. Assess for suicidal tendencies, especially during early therapy.
• Obtain weight and BMI initially and periodically during treatment in adults. Closely monitor height and weight in children. If clinically significant weight loss occurs, evaluate weight loss and consider discontinuation of therapy. Treatment may need to be interrupted if children are not growing or gaining weight as expected.

Implementation

• Follow titration guidelines when beginning therapy to minimize GI side effects.
• PO Administer without regard for meals.  DNC: Swallow tablet whole; do not crush, break, or chew. 

Patient/Family Teaching

• Instruct patient to take apremilast as directed.
• Advise patient, family and caregivers to look for suicidality, especially during early therapy or dose changes. Notify health care professional immediately if thoughts about suicide or dying, attempts to commit suicide, new or worse depression or anxiety, agitation or restlessness, panic attacks, insomnia, new or worse irritability, aggressiveness, acting on dangerous impulses, mania, or other changes in mood or behavior occur.
• Inform patient of risk of nausea, vomiting, and diarrhea. Instruct patient to notify health care professional if severe nausea, vomiting, or diarrhea occur; may need to consider dose reduction or interruption of therapy.
• Inform patient of need to monitor weight regularly. Notify health care professional if unexplained or clinically significant weight loss occurs; may need to discontinue therapy.
• Advise patient to notify health care professional of all Rx or OTC medications, vitamins, or herbal products being taken and to consult with health care professional before taking other medications.
• Rep:  Advise patient to notify health care professional if pregnancy is planned or suspected or if breastfeeding. Encourage patients to enroll in pregnancy registry for women who have taken apremilast during pregnancy 1-877-311-8972 to enroll or visit https://mothertobaby.org/ongoing-study/otezla/

Evaluation/Desired Outcomes

• Improvement in pain and function in patients with psoriatic arthritis.
• Increased healing of lesions in plaque psoriasis.
• Improvement in oral ulcers associated with Behçet's disease.